Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist

Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist
Name*
Date Completed*
MonthDayYear
Date
Date of Birth*
MonthDayYear
Date
Email*

Please answer the questions below, rating yourself on each of the criteria . As you answer each question, select the single choice that best describes how you have felt and conducted yourself over the past 6 months. This form can be be submitted and can be discussed during your next appointment with Dr. Flett*

	Never	Rarely	Sometimes	Often	Very Often
1. How often do you have trouble wrapping up the final details of a project, once thechallenging parts have been done?
2. How often do you have difficulty getting things in order when you have to do a task thatrequires organization?
3. How often do you have problems remembering appointments or obligations?
4. When you have a task that requires a lot of thought, how often do you avoid or delay gettingstarted?
5. How often do you fidget or squirm with your hands or feet when you have to sit down for along time?
6. How often do you feel overly active and compelled to do things, like you were driven by amotor?
7. How often do you make careless mistakes when you have to work on a boring or difficultproject?
8. How often do you have difficulty keeping your attention when you are doing boring orrepetitive work?
9. How often do you have difficulty concentrating on what people say to you, even when theyare speaking to you directly?
10. How often do you misplace or have difficulty finding things at home or at work?
11. How often are you distracted by activity or noise around you?
12. How often do you leave your seat in meetings or in other situations in which you areexpected to stay seated?
13. How often do you feel restless or fidgety?
14. How often do you have difficulty unwinding and relaxing when you have time to yourself?
15. How often do you find yourself talking too much when you are in social situations?
16. When you’re in a conversation, how often do you find yourself finishing the sentences of thepeople you are talking to, before they can finish it themselves?
17. How often do you have difficulty waiting your turn in situations when turn taking is required?
18. How often do you interrupt others when they are busy?

Type a question
Dr. JOHN FLETTjohnflett@mweb.co.zaMBChB(Pret), FCP(Paed)(SA), MRCP(Paed)(UK)Specialist PaediatricianHillcrest Private Hospital Rooms 031 7688122471 Kassier Road, Assagay, 3610 Fax 0866 857093Suite 8 Practice No: 3206181 Email: hillcrest@mweb.co.za Website: www.healthtalk.co.zawww.knowsomemore.o.za The information contained in this email is confidential and may be subject to legal privilege. The content of this email, which may include one or more attachments, is strictly confidential, and is intended solely for the use of the named recipient/s. If you are not the intended recipient, you cannot use, copy, distribute, disclose or retain the email or any part of its contents or take any action in reliance on it.If you have received this email in error, please email the sender by replying to this message and to permanently delete it and all attachments from your computer. All reasonable precautions have been taken to ensure that no viruses are present in this email and the company cannot accept responsibility for any loss or damage arising from the use of this email or attachments.
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